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10 yr experience of TOTALY laparoscopic pouches for UC

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12/04/2010

Laparoscopic restorative procto-colectomy: a 10-year experience of an evolving technique

 AC Goede, AR Dixon.  Dept., Colorectal Surgery, Frenchay Hospital, North Bristol NHS Trust, BS16 1LT

 

Corespondence: Mr Tony Dixon.

Anthony.Dixon@nbt.nhs.uk 

 

 

Keywords. Ileal pouch-anal anastomosis, Laparoscopic restorative procto-colectomy, SILS, Single port surgery

 Introduction

Large, long-term randomized controlled trials of laparoscopic surgery for colorectal cancer (MRC CLASICC1, COST2 and Barcelona3 trials) have all concluded that it is safe and associated with better short-term outcomes and without any compromise to long-term cancer survival.  NICE recommend4 that NHS trusts gave patients the option of laparoscopic resection as an alternative to open surgery provided that appropriately trained surgeons performed it. Restorative proctocolectomy (RPC) can also be performed using laparoscopic techniques5 -13. The surgery however is technically challenging and time consuming, and this will no doubt add to the ongoing debate regarding precisely how and where pouch surgery should be conducted. The aim of this study was to report our up-to-date experience of laparoscopic assisted and “total” laparoscopic RPC and highlight the difficulties of these two approaches.

 

 Patients and methods

A prospectively collected, password protected electronic database of all colorectal laparoscopic procedures performed between October 1999 and April 2010 has been used to identify surgical outcomes in 71 consecutive patients who have undergone laparoscopic restorative proctectomy – ileal pouch anal anastomosis (LRPC).

Operative technique

Our initial 3-port technique utilizing rectal mobilization within the TME plane, close division of the colonic mesentery with omental preservation has been previously described9. A 6cm Pfannenstiel incision was utilized in the first 40 patients to allow closure of the gut tube 1cm above the dentate line using the TX30G (Ethicon Endosurgery, Bracknell, UK), transection and retrieval of the rectum followed by construction of a 12cm W pouch. The pouch anal anastomosis was constructed under direct vision using a double staple technique. A suitable portion of ileum was chosen for the diverting loop ileostomy and drawn through the enlarged 12mm right iliac fossa (RIF) port-site. The subsequent 31 unselected patients underwent total laparoscopic mobilization with the specimen delivered (divided rectum end first) through the suitably dilated port at the site of the chosen ileostomy.  A 20cm J-pouch was created and returned for the pouch anal anastomosis to be carried out under direct laparoscopic vision.  The last 5 cases were carried out using a single port approach (SILS) from the proposed ileostomy site14.

Operative technique following previous subtotal colectomy

Pneumoperitoneum was established using a Verres needle inserted in the left upper quadrant. This was replaced with a 5mm optical port and 5mm 300 laparoscope. The latter was used to survey a site for potential further ports or in deciding to go for an immediate mobilization of the ileostomy (12mm port placed within a purse string once the stoma was mobilized with additional 12mm umbilical and 5mm inferior RIF ports i.e., the same as had been used for the previous colectomy)15. Single port restorative proctectomy (Olympus Tri port, Southend, UK) was used successfully in two cases after first mobilizing the end stoma.

Postoperative care

Analgesia was delivered via a PCA in 33 patients with oral morphine, diclofenac and intravenous paracetamol in the remaining 38; the latter was augmented by bilateral transversus abdominals plane (TAP) blocks16 in 23 cases. Patients were allowed fluids as tolerated, mobilized the following morning and offered a light diet. Discharge was determined by the stoma nurse’s assessment of competency at management of the new loop ileostomy. Catheters were removed after two days.

 

 

Results

Laparoscopic restorative proctectomy (LRPC) was attempted in 71 patients (39 males); 41 had undergone a previous colectomy & ileostomy (laparoscopic in 38).  The median age was 39 years (range 16-86) with a median BMI 24 (19-48kg/m2). Three had a cancer (Duke’s A, C and C) with a median nodal yield of 30. 40 underwent a hand sewn W-pouch construction via a Pfannenstiel incision whilst the most recent 31 patients had J-pouches constructed and returned via the ileostomy site. Seven underwent a single port (SILS) procedure (includes two procto-sigmoidectomies and ileo-anal pouch). There were five early conversions (7%) due to widespread, four quadrant adhesions. The median operation time was 210 minutes (range 75-330 minutes). There were no intra-operative surgical complications (other than spouting the wrong end of an ileostomy), or deaths.

Post-operative analgesia was provided by PCA in 33 patients for a median of 36hrs (range 24hrs - 7 days); 80% of PCAs were discontinued by 48hrs.  Median time to full diet was 36hrs (4hrs-7days) with a median hospital stay of 7 days (2-30). The median stay for the “incisionless” patients was 5 days, falling to 4 days in the single port cases (3-7).  Complications included: gastric ileus (9), high-output ileostomy (2), chest infection (2), PE, coagulopathy, anastomotic bleed & leak. There were no complications for the SILS cohort.  

Two patients received a blood transfusion. The anastomotic bleed occurred on the first post-operative evening. He underwent a laparotomy and evacuation of a haematoma four days later; the pouch was unaffected. The patient unfortunately went on to develop a below knee DVT. A wrongly spouted ileostomy was closed after a normal contrast study on day 9 (patient developed a leak 5 days later and the pouch was defunctioned). There was a minor wound infection/wound breakdown. 

Seven patients were readmitted (10%): high-output ileostomy (2), reactive depression, anterior anastomotic leak (drained at EUA), bolus obstruction (three admissions), DVT and reassurance/discharge home.  Covering stomas were closed at between 1-6 months; all are fully continent, able to suppress urgency and report a median pouch frequency of 4/24 hrs (2-8). Although function was not formally assessed using validated questionnaire or scoring systems, and was simply recorded as normal, impaired or absent, no patient admits to having new-onset problems with potency, dyspareunia and/or micturition. Long-term complications occurred in seven (10%) and included: incisional hernia following closure of the ileostomy (3), anastomotic narrowing requiring dilatation under anaesthesia (3) and a small bowel volvulus (no intra-abdominal adhesions) leading to mesenteric ischaemia and death.

 


Discussion

Continuous technological innovation has encouraged surgeons to attempt more complex laparoscopic colorectal interventions. The objectives remain the same: reduced postoperative pain, early mobilisation, reduced rates of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital, return to normal life, avoidance of incisional hernias and long-term improvements in cosmesis. Although laparoscopic intestinal surgery has been employed in a variety of settings, many traditionalists have been and remain, deeply skeptical about its application to inflammatory bowel disease.

Several specialist centres have shown the feasibility of laparoscopic restorative proctocolectomy5-13with complication rates similar to those reported with open surgery but with a shorter hospital stay.   A meta-analysis17 of nine studies (329 patients) compared open and laparoscopic RPC; 168 (51.1%) underwent laparoscopic resection. Operative time was significantly longer (86mins) in the laparoscopic group (p<0.001) and throughout the subgroup analysis, but this finding was associated with significant heterogeneity. Operative blood loss was lower (84mls) in the laparoscopic group. There was no significant difference in post-operative complications. Although they reported a median length of stay approaching 13 days for LRPC, a statistically significant reduction in length of hospital stay was observed for LRPC in high-quality studies and those studies reporting on more than 30 patients by 1.1 days (p=0.02 in both subgroups) and studies published in or since 2001 by 3.0 days (p=0.004) but not overall. The authors concluded that any potential advantage of a laparoscopic ileal pouch surgery remains to be established.

Our length of date data are considerably lower, yet similar to that reported by the Leeds group13 whose median length of stay was 6 (3-26) days overall. This series represents our total experience of LRPC and describes our move from using a traditional11-13,,15,17 Pfannenstiel incision to remove the specimen, transect the gut tube and create a W-pouch followed by a postoperative PCA (median stay 7 days)9, through to “incisionless” total laparoscopic resection with removal of the specimen through the chosen ileostomy site and construction of a J-pouch (median stay 5 days)11 to our current position of offering single-port LRPC (median stay 4 days)14.  This move has coincided with our move to “accelerated recovery” using TAP blocks to avoid the unwanted effects of parenteral opiates that delay recovery and discharge16.

The choice of incision to complete the dissection and to deliver the specimen remains a focus of debate.  In much of North America, Australasia17 and Europe11 a small peri-umbilical incision with direct extracorporeal ligation of the mesocolic vessels is popular. It remains our choice for performing resectional cancer surgery where it is our belief that in combination with TAP blocks, pain control is improved and recovery faster16,19. The fulcrum effect of using a linear stapler through a port, the limitation in the angulation of currently available staplers and the need for multiple firings are frequently quoted as being limiting factors in allowing laparoscopic low rectal transection13,20,21.  Pfannenstiel incisions have been used to overcome these perceived problems13.  An alternative approach adopted by others is to use a supra-pubic port, hand-port22 or incision.  We have learnt through experience19 that it is possible in all but the largest of tumours and narrowest of android pelvises to transect/staple the gut tube low down at the level of the pelvic floor using an ATG45 (Ethicon Endosurgery, Bracknell, UK) introduced from the right iliac fossa using two anterior-posterior firings.  The secret is in dissecting/defining the “gut tube” and pelvic floor (optimized by using a 300 laparoscope) and more importantly utilize the fulcrum effect of the port by placing the stapler with a fully pronated forearm, flexed wrist and an internally rotated, abducted shoulder.  The linear cutter will flex and close at 900 if the tip is pressed against a fixed structure i.e., pelvic side wall/sacrum, a fist placed against the perineum; once the pressure is released it will “return” to 450 and allow firing.  A Spackman uterine retractor22 not only helps with the dissection, but once completed, keeps the vagina under tension and away from pouch anal anastomosis.

Although we would consider our 34% morbidity (all complications plus readmissions) a little high (the comparable figure18 for segmental resection in our unit is 22%), it is vey similar to that reported by others11,12,22,25.  This figure falls to a more acceptable 14% if one excludes gastric ileus and high output stomas, which are more appropriately considered side effects of the transverse colectomies and covering ileostomies. The DVT/PE occurred in a patient who went on to be diagnosed as factor VLeiden deficiency.  51 (72%) patients had an uncomplicated recovery. Sadly we were unable to match the 0% conversion rate in 36 patients recently reported by the Leeds group13; dense impenetrable adhesions necessitated early conversion in 7%, a rate similar to Kienle et al11 8% in 50 patients. LRPC may have an important role in maintaining fertility; 71% of 34 female study patients were found to have no adnexal adhesions at laparoscopy prior to ileostomy closure and no patient had adhesions affecting both adenaxea)26. This figure is significantly lower than previously reported for open operation with or without the use of adhesion barriers. The one late fatality in this present series followed a small bowel mesenteric volvulus; the complete absence of any adhesions, including the free edge of the mesentery of the afferent limb of the pouch probably had a major role in its development.

Whilst all our patients, and in particular the SILS subgroup were delighted with the cosmetic results of their surgery, Dunker’s comparative study7, in which a midline wound was used, failed to demonstrate a significantly higher body image score compared with that obtained following conventional surgery; cosmetic scores, however, were significantly higher in the laparoscopic group. This small study showed no difference in functional outcome and quality of life scores between the two contrasting approaches to treatment. The Mayo group27 examined a larger subset; 125 of 289 patients (43% responders) were questioned one year after operation to evaluate sexual function, body image, and quality of life. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between responders and those who did not. There were no differences in results between laparoscopic and open patients using the three survey instruments. Whilst orgasmic function scores were significantly lower in men who underwent LRPC compared with open procedures, overall, sexual function scores were equal to, or better than normal values for men but were lower in women. Interestingly, overall body image and quality of life scores were above the means published for the United States.

It is contentious whether laparoscopic rectal surgery itself is associated with a higher incidence of bladder and sexual function compared with open surgery; 41% of CLASICC1 patients reported a severe change in sexual function, compared to 26% in the open group (not significant). The groups however were poorly matched and there were more TMEs in the laparoscopic group. The Brisbane group28 report a more appropriate 6% sexual dysfunction in 101 male patients; this falls to 2% when the effect of radiotherapy is excluded.  Whilst the pelvic dissection is technically challenging, particularly when mobilizing a fibrosed defunctioned rectal stump in a male with a narrowed pelvis, the magnification does afford a superior view of the autonomic nerves, particularly behind the seminal vesicles and a 300scope allows one to “look around corners”. The main problem with laparoscopic TME is that it is very easy to tent the hypogastric nerves by retracting in a cranial/lateral direction, particularly on the left hand side, and if the operator is unaware of this difference from open surgery then it is very easy to enter the presacral plane and damage the nerves.  This effect is reduced if you do not employ an assistant to hold the recto-sigmoid.   

We have shown that laparoscopic restorative proctocolectomy with ileo-anal pouch is technically feasible and can be performed without an unduly lengthy operation or morbidity. More importantly, it is safe and predictable with good functional outcomes.  However, the procedure is difficult and technically demanding and requires lots of concentration. No one should embark on LRPC unless they are adept at laparoscopic TME and ultra-low rectal transection.

 

References

1.              Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, Heath RM, Brown JM, MRC CLASICC trial group.  Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365:1718-26.

2.              The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer.  N Engl J Med 2004; 350:2050-9.

3.              Lacey AM, Garcia-Valdecasas JC, Delgado S et al., Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer; a randomized trial.  Lancet 2002; 359: 2224-2229.

4.              National Institute for Health and Clinical Excellence (NICE).  Laparoscopic surgery for colorectal cancer.  London (UK): National Institute for `health and Clinical Excellence (NICE); 2006 Aug. (Technology appraisal guidance; No. 105). http://www.nice.org.uk/nicemedia/pdf/TA105guidance.pdf

5.             Thiabault C, Poulin EC. Total laparoscopic proctocolectomy and laparoscopically assisted proctocolectomy for inflammatory bowel disease: operative technique and preliminary report. Surg.Laparosc.Endosc., 1995; 5: 472-476.

6.             Marcello PW, Milsom JW, Wong SK, Brady K, Goormastic M, Fazio VM. Laparoscopic restorative proctocolectomy: a case-matched comparative study with open restorative proctocolectomy. Dis.Colon Rectum 2000; 43: 604-8.

7.             Dunker MS, Bemelman WA, Slores JFM, van Duijvendijk, Gouma DJ. Functional outcome, quality of life, body image and cosmesis in patients after laparoscopic assisted and conventional restorative proctocolectomy. Dis Colon Rectum 2002; 44: 1800-1807.

8.             Ky AJ, Sonoda TM, Milsom JW. One-stage laparoscopic restorative proctocolectomy: an alternative to the conventional approach? Dis Colon Rectum 2002; 45: 207-211.

9.             TS Gill, A Karantana, J Rees, S Pandey, AR Dixon Laparoscopic proctocolectomy with retorative ileal-anal pouch.. Colorectal Disease 2004; 6: 458-461.

10.         Larson DW, Dozois EJ, Piotrowicz K, Cima RR, Wolff BG, Young Fadok TM.  Laparoscopic assisted vs open ileal pouch anal anastomosis: functional outcomes in a case matched series. Dis Colon Rectum 2005; 48: 1845-50.

11.         Kienle P, Z’graggen K, Schmidt J, Benner A, Weitz J, Buchler MW. Laparoscopic restorativeproctocolectomy. Br.J.Surg 2005; 92: 88-93..

12.         Larson DW, Cima RR, Dozois EJ, Davies M, Piotrowicz K, Barnes SA et al. Safety, feasibility and short-term outcomes of laparoscopic ileal pouch anal anastomosis: a single institutional case-matched experience. Ann Surg 2006; 243: 667-70.

13.         McAllister I, Sagar PM, Brayshaw I, Gonsalves S, Williams GL. Laparoscopic restorative proctocolectomy with and without previous subtotal colectomy.  Colorectal Dis. 2009; 11: 296-301.

14.         Chambers W, Bicsak M, Lamparelli M, Dixon AR. Single-incision laparoscopic surgery (SILS) in complex colorectal surgery: a technique offering potential and not just cosmesis. Colorectal Dis 2010 [Epub ahead of print].

15.         Fowkes L, Krishna K, Menom A, Greenslade GL, Dixon AR. Laparoscopic emergency and elective surgery for ulcerative colitis. Colorectal Dis 2008; 10: 373-8.

16.           Zafar N, Davies R, Greenslade GL, Dixon AR.  The evolution of analgesia in an “Accelerated” recovery programme for resectional laparoscopic colorectal surgery with anastomosis.  Colorectal Dis. 2010;

17.           Rickard MJ, Young CJ, Bissett IP, Stitz R, Soloman MJ. Research committee of the Colorectal Surgical Society of Australasia. Ileal pouch-anal anastomosis: the Australasian experience. Colorectal Dis. 2007; 9: 139-45.

18.           Tilney HS, Lovegrove RE, Heriot AG, Purkayastha S, Corstantinides V, Nicholls RJ, Tekkis PP. Int.J.Colorect Dis. 2007; 22: 943-51.

19.           Dalton SJ, Ghosh A, Greenslade GL, Dixon AR. Laparoscopic colorectal surgery – why would you not want to have it and more importantly, not be trained in it? A consecutive series of 500 elective resections with anastomosis. Colorectal Dis. 2009 Nov 2. [Epub ahead of print].   

20.           Bergamaschi R, Essani R.  Laparoscopic resection for rectal cancer: are we there yet.  Colorectal Disease 2009; 11: 1-2

21.           Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N.  Relationship between multiple numbers of staple firings during rectal division and anastomotic leakage after laparoscopic rectal resection.  Int J Colorectal Dis 2008; 23: 70.

22.           Maartense S, Dunker MS, Slors JF, Cuesta MA, Gouma DJ, van Deventer SJ et al. Hand assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomosis: a randomized trial. Ann Surg 2004; 240: 984-91.

23.           Varey AH, Darweish A, Pandey S, Dixon AR. Laparoscopic anterior resection and uterine manipulation: why make things difficult? Colorectal Dis 2005; 1: 104-5.

24.           Ouaissi M, Alves A, Bouhnik Y, Valleur P, Panis Y. Three step ileal pouch anal anastomosis under total laparoscopic approach for acute severe colitis complicating inflammatory bowel disease. J Am Coll Surg 2006; 202: 637-42.

25.           Maartense S, Dunker MS, Slors JFM, Gouma DJ, Bemelman WA. Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: a case-matched study. Colorectal Dis 2004 ; 6: 254-7.

26.           Indar AA, Efron JE, Young-Fadok TM. Laparoscopic ileal pouch-anal anastomosis reduces abdominal and pelvic flor adhesions. Surg Endosc 2009; 23: 174-7.

27.           Larson DW, Davies MM, Dozois EJ, Cima RR, Piotrowicz K, Anderson K, Barnes SA, Harmsen WS, Young-Fadok TM, Wolf BG, Pemberton JH. Sexual function, body image, and quality of life after laparoscopic and open ileal pouch-anal anastomosis. Dis Colon Rectum 2008; 51: 392-6.

28.           Jones OM, Stevenson ARL, Stitz RW, Lumley JW. Preservation of sexual and bladder function after laparoscopic rectal surgery. Colorectal Dis 2008; 11: 489-495.

 


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